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True Anomaly

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True Anomaly last won the day on October 8 2016

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About True Anomaly

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    Emergency Medicine PA


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    Physician Assistant

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  1. In the interest of not having this thread further devolve, am locking it If you wish to continue discussions about topics raised on this thread, please continue it in another thread
  2. Unpopular opinion- I love EMRs There is no question that paper charting is easier to use for the provider- quick and simple to fill out, especially with templates like T sheets. However, what I was always frustrated by when I did paper charts was the inability to read someone else's handwriting. A LARGE part of medicine is the ability to communicate with other providers, whether in your own system or in other systems. It's rare to encounter a patient who hasn't been touched in some way by the medical system, and many patients have already been evaluated by someone that saw them for the issue that they may be seeing you for. It's extremely important for me to know what has been done for the patient in front of me already, and even more important is the rationale as to why and why not certain things were done. It is much easier to read this in an EMR than trying to decipher someone's handwriting, and then contacting them to discuss it if you can't read it. For me, this avoids repeat testing, avoids unnecessary admissions, unnecessary procedures, unnecessary prescriptions, etc. I believe we're nearing the end of an approximately 20-year era of transition from purely paper charting to purely EMR. Doing so has had NUMEROUS trials and errors, some worse than others, but it's gradually improving and moving to a point where multiple systems can see the same thing. Are EMRs perfect? Of course not. I get the arguments that they're built for billing and not for charting and purely medical use. However, they've gotten better over the years, and you'll never convince me that in order to allow others to read what you're writing that it's better to have paper charts over EMRs. You can't convince me that it's not helpful to see that an admission to a hospital in other state with the full consults, discharge summaries and rationales available to you to review on a patient who presents in front of you for an issue related to that admission. I can't rely on what the patient tells me, and I doubt I'm alone in that thinking. You're not just charting for your own sake- you're charting for others to be able to read what you're doing and why. I am convinced that once I fully understood that concept that I became a better PA
  3. I do inner city level 1 trauma center exclusively. Like many of you, I’ve seen a significant downturn in volume, but that’s starting to rise back up over the past week. While hours across the board have definitely been cut- I’ve lost 3 shifts this month at least- with the rising volume, I was called yesterday and asked if I could come in for a few hours to help with volume. We do have a tent outside where all patients other than sick EMS patients are routed through initially- if they “screen in” for COVID which is basically fever/cough/dyspnea/diarrhea/abd pain/vomiting they Stay in the tent, and a PA/NP screens them there with nursing. Regarding COVID- if they aren’t actually struggling to breathe or have conversational dyspnea or hypoxic, then they’re discharged- we’re not at a point of being able to test the worried well or those with minor sx’s. The sicker folks get rooms in the ED, and work up proceeds as normal. I’ve gone back and forth with how to handle the non emergent patients over this past month. Due to low volumes, little revenue is being generated of course so I thought when I saw them up front it might be best to let them go to the back, let the docs pick them up and generate RVUs (I work for a group where the docs are purely RVU based and the PAs/NPs are hourly with no production bonus). But doing so puts them at risk simply by being in the ED of getting COVID, and everyone agrees that while it sucks to not be generating income, from a patient safety perspective if they shouldn’t be in the ER then just discharge them as soon as you can. So I’ve spent most of my shifts discharging the non emergent stuff from the waiting room or tent. I’m really not seeing patients in the ED much, other than when I got to work recently and one of the docs had two critical patients who needed central lines so I was asked to do those. We’re all wearing N95s the entire shift, no matter what type of patient we see. One of my fellow PAs was able to find P100 respirators which I purchased for both myself and my wife (she’s an ER doc at another hospital), so I wear a P100 for every patient encounter. For the higher risk patients, I’ll wear a face shield and gown as well. I don’t mind people coming in for nonemergent stuff- that just comes with the territory, and I never let those folks linger around for too long anyway. But what is the most frustrating part of this whole ordeal- besides being cut hours of course- is primary care clinics or specialists who are still referring people to the ER for things that truly don’t need to be in the ER. I’ve gotten used to clinics using the ER as a faster way to get nonemergent testing done, but it still continues during this whole thing, and there is truly no higher risk place to get COVID than the ER.
  4. Other than the word “supervision”, what about this is not exactly what OTP is at the very heart of it? Team-based practice, decided at the practice site, without the need for unnecessary government red tape? Or are people upset because it’s not a complete break from doctors period, and therefore nothing was going to satisfy other than total independence? They could’ve done nothing at all and sat on their hands. Let’s at least acknowledge SOME movement in the right direction, even if it’s not exactly what you wanted ideally
  5. Volume down for us in our ER, but hours haven’t been cut yet. We’re expecting the surge to hit in about 1-2 weeks though, which is likely why we haven’t been cut yet
  6. Wow, I didn’t realize an antibody test was becoming that readily available. I think that’s amazing. Seems logical to screen with the antibody test (provided of course you have enough) before doing confirmatory PCR testing of the RNA itself. Is the antibody test looking for both IgM and IgG, or just IgM? I’m sure here in the future we’ll all pretty much have a positive IgG test
  7. Finally had my first true positive covid case yesterday Manning the tent at my place of practice- 29 y/o comes in, no med hx, states he was traveling to NYC for the past two months, and a coworker tested + for covid last week. Sx’s of cough and fever for the past week, but last two days notices that his breathing is just wrong. Guy is ambulatory, afebrile, mildly tachycardic, but also having conversational dyspnea and looks uncomfortable. Got him a room for further evaluation- checked this AM and sure enough, tested positive. Even though, like y’all, I’m reading as much as possible about how this disease looks in patients who are presenting, but the more first-hand look you get at it when patients like this guy are borderline- you can definitely see that had this guy not come in, another day and the chances of him having respiratory failure were very high
  8. Starting to? I was there 3 weeks ago. Just give it to me so I can deal with it and get over it. Then I likely won’t even need PPE to see patients (cue the study that is now showing worsening morbidity with re-infection...)
  9. If someone is being told they can't wear something to protect themselves while doing direct patient care because it "wasn't purchased by the hospital", that's an VERY easy story for a local media outlet to blow up. Myself and my other colleagues at work have bought eye protection online. There's no way anyone is going to tell me that I can't use equipment that I purchased for myself in order to practice safely
  10. Community spread is here. If it’s not already in your backyard, it’s coming soon. In my opinion, it is at the point that the availability of testing should be guiding evaluation and management. If someone shows up to an ER and If you As the evaluating PA don’t have ready access to testing, then unless they are truly in extremis and needing of supportive care- ie, ventilatory support- then they get DISCHARGED and advised to quarantine. If testing is available, then by all means test in order to establish the cohort and potential for exposure. But even if they test positive, they’re not staying in the hospital. So....off to home you go anyway Most places, mine included, have ready access to a respiratory PCR panel (it’s amazing what you find you have access to in times like this) which tests for just about every respiratory virus and even a few bacteria. Although a positive on that PCR doesn’t mean rule out a co-infection, it certainly makes it far less likely that you have COVID- and at this point I think a valid clinical decision can be made. Bottom line- the current triage process for asking about symptoms and possible exposure to a know patient is unhelpful. If they don’t have it now, they likely will soon. Holding the dam for just a few more days/weeks until testing become much more widely available is going to be the hardest part
  11. Anecdotally, I have heard large hospital systems now barring ANY travel for their employees
  12. There is no state law that mandates that if a patient asks to see the physician that you must allow them. There may have been in the past, but there is no current law that says this It’s good to ask for the exact wording, but My bet is you won’t find it. Can’t quote something that doesn’t exist.
  13. The NPs obtained the ability to be directly reimbursed for their services in 1997 with the change in Medicare law. That's what started the snowball downhill for their independence I've said it before and I'll say it again- until we ALSO have this ability, the road to OTP/FPAR/whatever autonomous/independence term you wish to use will be a much harder one to travel. It becomes a much easier case when you completely control your own financial future. The NPs laid out the playbook already. There's no sense in rewriting it- follow what they have done already
  14. Fascinating Something else I learned reading this, if I’m reading this correctly- unlike the three most famously-known survivors of Ebola (the initial physician from Fort Worth who got sick, as well as the two nurses from Presbyterian hospital in Dallas), it doesn’t sound like the PA got the experimental treatment- just aggressive supportive care. So if Ebola victims receive this, maybe they have more than a puncher’s chance of survival? Or maybe he did get the experimental drug and the article doesn’t mention it
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